Wednesday, July 30, 2008

Takebackers

A transplant surgeon I trained under in Chicago once told me that one of the worst errors a surgeon can make is failure to return a patient to the OR in a timely fashion. In transplant surgery, you're dealing with coagulopathic, extremely ill patients who undergo commando abdominal operations; post operative bleeding can be a commonplace occurence. It was no big deal for those guys to bring a post op liver transplant back to the OR to evacuate a hematoma, even multiple times.

For most general surgeons, however, a return to OR is a major complication. It gets you on the Morbidity and Mortality list. The QA committee sends you a letter. It's a sign of error. You did something wrong. You closed the skin leaving something undone.

It's human nature to deny any intentional wrongdoing. You run the case through your mind. Everything seemed fine. It was dry when you closed. The anastomosis looked beautiful. You checked the ureter. The clips seemed in good position on the cystic duct. So why is the patient not doing well? Could it possibly be related to something I did?

Well, yeah. It's always a possibility. And if the patient is leaking or bleeding or whatever, it isn't going to get better all by itself. In fact, the longer you wait, the worse the final outcome will be. It's amazing how a normally astute general surgeon suddenly transforms into a psychiatry resident in the post-operative period when things start to deteriorate. Peritonitis on exam? Oh, that's probably just pain from the incision. The patient's hemoglobin drifts from 12 to 7 in 24 hours? Hell, it's dilutional! Surely he's not bleeding anymore!

I'd sit next to the aforementioned transplant surgeon at M&M meetings in Chicago and he'd just shake his head. What the hell were they waiting for? A return to the OR may not be the crowning achievement of a surgeon's career, but it may very well be the act that saves a patient's life.

Sunday, July 27, 2008

The lesion

There wasn’t anything unusual about her at first glance. She seemed like the typical grandmotherly 68 year old lady that I see every day. She lived alone. Her four kids were in the area and she saw her grandchildren most weekends. She had been a homemaker most of her life. She lived comfortably off her husband’s pension and her own social security. She was in the hospital for “weakness and fatigue”. The internist had run a battery of tests, sent bloodwork, consulted half a dozen specialists. The investigations were unrevealing. Her heart was ok. She had some mild cortical atrophy. She was a little anemic but the upper and lower endoscopies were negative. She looked thin and wan when I walked into the room to introduce myself. She seemed to sink into the crevices of the hospital bed with a defeated resignation. Her voice was tepid and quiet and I had to pull the chair up close to the bed to hear her.

I had been called with regards to a “lump” on her back. How long has it been there, I asked her gently. She looked away, pausing for a moment. It’s so embarrassing, she said. I should have seen someone sooner. I neglected myself. She couldn’t look at me. She kept staring at her hands folded across her lap. It’s ok, I said. Would you mind if I took a look?

I helped her with the buttons on the hospital gown. At the tip of her shoulder blade was a giant gauze dressing. As I moved to peel back the tape holding it in place, a foul, festering odor was released. The gauze was heavy with moisture. I'm so sorry, she said. I know it smells. It's fine, I said. Underneath the dressings was a tennis ball sized fungating mass, serum seeping from the ulcerated surfaces. She slowly shook her head with her eyes closed, wrinkled hands folded across her mouth like a steeple.

-How long has it been there?
-Two years, she whispered. I thought it might just go away.
-Does it hurt?
-No. Only sometimes. If I bump it. I ought to have seen someone sooner. I was so busy taking care of my husband. He was ill, you know. I didn't want to think about anything else. I didn't have time....

For two years she functioned as a caretaker for her deteriorating husband. She fed him, bathed him, cleaned him when he soiled himself. Everything was directed toward him, all her energies, everything outside herself. Is this a deeper form of love, this extreme self denial? I had to sit down. I couldn't say anything. I covered her back up. We sat in silence in that dim little hospital room for a good five minutes. This quiet, frail little old lady. No one in the family knew what she had quietly endured. She had downplayed her husband's decline. Denied all offers of assistance. Always kept the lesion carefully concealed and perfumed. And now she was done hiding. She was here.

-You must miss him, I said after a time.
-You have no idea, she said, looking at me finally. And suddenly, I thought I saw a glint of determination in her eyes, the very drive that had gotten her through the past two years.
-But I want to get better now, she said. I just hope it isn't too late.

A core biopsy revealed a poorly differentiated malignant melanoma. After lymphoscintigraphy confirmed that the right axilla was the primary lymphatic drainage basin, we proceeded with a wide local excision and concommitant sentinel node biopsy. Melanoma, as opposed to other skin cancers (squamous, basal cell), has a tendency to spread to the regional lymphatics. The thicker the melanoma, the higher the chance of metastasis. As I began the axillary dissection, my heart dropped as I encountered clumps of matted, enlarged lymph nodes. The lesion itself was excised uneventfully, a twenty minute procedure, and just like that it was gone.

When I saw her in the office a week later for drain removal and a discussion of the final pathology she wasn't alone. All four of her daughters accompanied her. The two flanking her sides both held her hand. There was a rosy color to her cheeks that was lacking a week before. She smiled. She seemed at ease, finally. Surrounded by her loved ones, the burden of concealment cast off, comforted by her new-found transparency.

The most important factor in melanoma staging is thickness, usually discussed in terms of millimeters. Her melanoma was 5 centimeters thick, an exponentially thicker lesion than what we typically encounter. But the margins were clean and her wound had healed nicely. What about the lymph nodes, one of the daughters asked. Amazingly, all the lymph nodes were negative, I said. Some of them were enlarged but this was secondary to reactive inflammation rather than metastatic spread.

And then that little exam room became the warmest, most festive place in northeast Ohio. There was crying and laughing and squeals of delight. My patient's eyes glistened with tears, her shoulders shuddering. I tried to modulate the excitement somewhat (still a big lesion, poorly differentiated, etc) but not too much. Now was a time for good news and optimism. The pathology on the lymph nodes was entirely unexpected; I never would have guessed it.

It seemed the rest of the family was committing to my patient in the same fashion that she had done for their father. She was moving in with the eldest daughter. The girls were taking care of everything. Things were going to get a lot easier. Never again would she have to endure anything on her own. She hugged me on the way out, even gave me one of those embarassed quick pecks on my cheek.

When I'm in a room with a patient, I try to keep my emotions in check. You don't want some doctor breaking down in front of you, turning into a blubbering sack of goo. Sitting here on a Sunday writing this story allows a different perspective. For some reason I have a hard time letting go of this particular patient. She had something to teach me; and the further I get from the actual events, the more I seem to understand. I'm still quite young, and have a lot to learn. I'm grateful for the opportunity to interact with human beings in the intimate setting that the doctor/patient relationship affords. I think we all carry our own lesions with us throughout life, whether it resides on our back, or our leg, or deep within the recesses of our hearts. We all have them. There's no shame in that. And it's a good thing to know that the burden can be lessened the moment we decide to reveal it, the moment we decide we don't want to endure it alone anymore....

Wednesday, July 23, 2008

Are you guys ready for this?

Another July has arrived, bringing with it another fresh batch of young, impressionable, enthusiastic general surgery residents. According to statistics, most will end up doing fellowships and pursuing jobs with minimal call coverage such as "breast surgeons" or "minimally invasive surgeons". Whatever that means. But some die-hards will stick it out and take a job as a true general surgeon in a community hospital setting. Those that do are going to have weekends like my recent Fourth of July weekend; a weekend straight from hell.

Looking at the call schedule on the preceding Wednesday, I noticed that I was on trauma call at one hospital and ER call at another that weekend. I was also covering another busy general surgeon who was out of town on vacation. It was a confluence of circumstances conspiring simultaneously to create a perfect storm.

I went to sleep Thursday night at around 11. I woke at 5am and worked all day. At around 4pm the pager started and wouldn't stop, smoking from my hip. Level I trauma. Appendicitis. Diverticular bleed. I never went home Friday; operated all through the night, and then went straight from the OR to the floor so I could get rounds started. We had fifty (yes, five-oh) patients in both hospitals combined. I rounded for 7 hours on Saturday morning. New consults, new admits, pages of names on my list. I got home around 2:30pm, ate a Pizza pocket and mowed the front lawn. Your pager's going off again, my wife called out to me. Back to the hospital at 5pm. Free air, another level I trauma, a sick patient in the ICU, an incarcerated hernia. Again, I operated all through the night. At 5am on Sunday morning, I crashed out on the floor of my office for 45 minutes, not really sleeping, but not really conscious either. The pager went off again. I started rounds, struggling to concentrate, but getting through it. I started having paranoid thoughts that the Starbucks guy had given me decaf instead of the Americano I had ordered. I got home around 1pm. The backyard needed mowed. I can't stand asymmetry when it comes to back and front yard grass length. I mowed the back yard. What the hell are you doing?, my wife yelled out at me. I ate like a wild boar Sunday evening. I stuffed myself and ate and kept eating. I hadn't had a regular meal in almost 48 hours. Then, for some reason, I couldn't just go to sleep. I was wired and anxious and kept telling rambling incoherent stories. Finally, I dozed off at around 10pm. But the pager went off like clockwork every hour on the hour until my alarm went off at 5am on Monday. I showered and shaved for the first time in three days and went into the hospital to make some rounds. My partner took one look at me and told me to beat it after lunch. I got home around 3pm and crashed out for the night shortly thereafter.

Now this wasn't by any means a typical call weekend. It was an exceptional weekend; nonetheless it happens two or three times a year. You just have to suck it up. I made it through just fine. I took care of a lot of patients. I did some good work. No one was compromised by my lack of sleep. I couldn't do it every weekend, but every once in a while duty calls.

So you're a general surgery intern. You'll be working 80 hour weeks (and possibly less than 60 hrs if further reforms are implemented). Post call, you'll be eating a nutritious breakfast and reading the newspaper in the comforts of your own home by 8am, irrespective of any work that remains to be done on the patients you cared for over the night. The next day, you'll show up bright eyed and bushy tailed and completely clueless about what happened to the bowel obstruction you admitted while on call or the results of the CT scan that you ordered on the ER patient who had some vague LLQ abdominal pain. But hey, you'll be rested. You probably got a chance to read three chapters of Sabiston. You'll ace the inservice exam.... but will you be ready for the sort of weekend I just described when you're an attending surgeon?

Sunday, July 20, 2008

Surgery on the Elderly

This article in the NY Times caught my attention the other day. The ethical implications of performing potentially life saving invasive procedures on the extreme elderly (nonegenarians and centarians) is addressed in the usual superficial, newspaper way. But it's a topic that will become more and more relevant as the American population continues to age.

Certainly, rationing of health care is something that is an inevitable component of any potential "universal" health care system that gets implemented in the future. Resources are limited and there's a finite amount of federal money to finance the endeavor. Something has to give. Certain subsets are going to have to do without.

But you start to tread in dangerous waters when you use arbitrary data points like chronological age as a determining factor in who gets the colectomy and who has to die with the bleeding sigmoid tumor. Age is a number. As is weight and height and your 40 yard dash time. Statistically, a patient who is 95 years old obviously has a higher risk of having major complications following routine surgery compared to a 35 year old. But are the risks any higher than in a 58 year old obese male with CAD, DM, three stents in his coronaries, on Plavix and aspirin? I'll choose the 95 year old who takes lipitor and last visited a hospital for the birth of her last child 60 years ago every single time.

Last week I rushed a 97 year lady to the OR for an incarcerated inguinal hernia. She lived in an assisted living facility near her son, was completely coherent, and spent most of her afternoons listening to classical music and chatting with her little old lady friends. The surgery went well. She went back to the facility on post op day 3. What if there was a policy limiting what I could offer her, just because she was older than say, 95 years old? Why is that even an ethical question? Someone on my post on the passing of Michael DeBakey questioned the "ethics" of his thoracic aorta surgery when he was 97. Well, he recovered and went ultimately went home. There isn't anything "ethical" about operating on a coherent, informed, vibrant human being who chooses to undergo a potentially dangerous procedure for the purpose of alleviating a source of unnecessary suffering. It transcends all questions of ethics. We don't need committees to meet and pontificate and decide what to do in those situations. It's simply treating a human being with the respect and dignity that they deserve. That ought to come natural, if you're a physician who's worth a damn. Let's save the ethics committees for the truly vexing cases; the demented 82 year old languishing in an ICU with decubitus ulcers who's only live family member wants her to have a PEG tube and an AV fistula for dialysis....

By the way, I had posted about an emergency operation on a 99 year old lady. She actually recovered and went back to her nursing home, celebrating her 100th birthday last month....

Saturday, July 19, 2008

Prasad

I had a chance last night to revisit an old technique I had learned in residency; the Prasad colostomy. This was an ancient lady who had had an major operation on just about every significant blood carrying artery in her body over the past ten years, who presented acutely in the ER with abdominal pain. Vasculopaths like this who present with a chief complaint of acute abdominal pain ought to set off internal alarms in the heads of any decent general surgeon. Mesenteric ischemia goes right to the top of the list of the differential diagnoses.

Basically, she had peritonitis on exam, thereby obviating a bunch of hemming and hawing on whether or not to get an angiogram so I booked her for the OR. I opened and found a hemorrhagic infarct of the sigmoid colon. Ten minutes later about a foot of bowel was in a dish on the back table. Although pink and grossly well vascularized, I was worried about doing a primary anastomosis in a case of mesenteric ischemia, especially when I wasn't sure about her remaining vascular anatomy (history of aorta-bifemoral bypass in the distant past). And maybe I was a little bit of a wuss. Whatever. So I mobilized the descending colon and the rectosigmoid distal stump and brought them both through the same stoma aperture in the left lower quadrant, sort of a like a double barrel colostomy. The variation of the Prasad is that you only mature a corner of the distal stump, tacking it to the proximal stump which is fully matured in the standard fashion. The benefit is that it is much easier to re-establish intestinal continuity down the road compared to a standard Hartman's colostomy. Often you just have to make a small incision around the colostomy, staple the ends together, and pop it back into the abdomen. Also, the Prasad gives you easy access to both limbs of large bowel; useful if the patient doesn't do well and you want to inspect the mucosa for progressive ischemic disease.....

Friday, July 18, 2008

Single Incision Kidney Harvest

Transplant surgeons at the Cleveland Clinic (i.e. the Evil Empire) are starting to perform donor nephrectomies through the new technique of single port laparoscopy. Generally, laparoscopic surgery is done via multiple tiny incisions for multiple ports; one for the camera, one for the retractors, one for the tools, etc. Single port access involves making one incision by the umbilicus through which a multi-holed port is placed. As a result, you are left with a single, small, unobtrusive scar deep in the folds of the belly button.

As far as I'm concerned, this is the next stage of minimally invasive surgery. Incisionless surgery (NOTES), on the other hand, is not the way of the future. Imagine presenting a hypothetical patient with the two options:

Option 1: Guess what Mrs. Y? I can slash a hole in your vagina, reach inside and wrench out your gallbladder! Isn't it cool that I can do that? Here, sign this consent form.

Option 2: You need your gallbladder out Mrs Y. To do so, I need to make a very small cut in the folds of your belly button through which all my tools and camera will enter your abdominal cavity. You'll go home the same day and have very little post-operative pain.

Obviously I'm being just a wee bit disingenuous, but the fact remains that most female patients requiring cholecystectomy or appendectomy or Gyne procedures are of child bearing age. I just don't see NOTES taking off when you have to get women to wrap their minds around the idea of having an intentional injury created in the vagina. Plus, it requires teaching thousands of surgeons an entirely new technique, whereas single port laparoscopy utilizes existing technical knowledge....

Anyway, This Dr Gill at the Cleveland Clinic has now done 11 donor nephrectomies via the single port technique, with good results so far. So if you're looking to put a kidney on the open market, make an appointment with this guy. Just think twice about having any kind of orthopedic intevention down there, especially if you're a professional athlete on the Cleveland Browns....

America's Turkish Prisons

I ran across this lovely column in my local daily rag the other day. What a wonderful service Ms. Suchetka provides to her greater Cleveland readership with her insights on the dangers and horrors of being hospitalized in 21st century American hospitals. Because you know, having a loved one in the hospital is akin to sending them to some third world infirmary in a prison run by the local military junta. The horror, the horror....

She advocates constant surveillance of granny as she languishes in her air conditioned, wood floored private room. Family members ought to work in shifts, keeping a a close eye on her. Heck, you even might want to consider hiring personal bodyguards/thugs to make sure those evil doctors/nurses aren't doing anything in a typically malicious fashion. Because why else would 87 year old granny with her broken hip and pneumonia acquire something like a bedsore or c diff colitis? It must be the nefarious medical personnel! So gear up America! Get your Pinkertons gumshoe at the bedside of your loved one if fortune should ever necessitate a hospital stay; their lives may depend on it!

Thursday, July 17, 2008

Tangled Up in Blue

I was seeing a new patient the other day with regards to a hernia or a gallbladder or whatever and, during the interview, she related a history of having a "failed kidney" on the right side.

-Why did the kidney fail? I asked.
-When they were doing my hysterectomy, the "urether" got tangled up in some adhesions, she said.
-When was the hysterectomy?
-Oh lord, maybe 30 years ago.
-I see.
-They had to go back in and try to untangle it a few days later, but the kidney died anyway, she said.

Here's a translation: During her hysterectomy, the right ureter was injured and probably even tied off with a suture. She subsequently developed hydronephrosis and eventual right renal decompensation. The injury was probably not identified at the initial surgery because she returned to the OR a few days later for the "untangling". It's amazing what physicians could get away with back in the old days of paternalistic, ask no questions delivery of health care. Open disclosure, as more recent studies demonstrate, doesn't necessarily correlate with higher rates of litigation; moreover, it removes the unsavory taint of lies and distortion of the truth that can follow a patient around the rest of her life...

Wednesday, July 16, 2008

Antibiotic Nazis

This was quite interesting. I operated on a little girl the other night for a perforated, gangrenous appendicitis. Laparoscopically, I removed the nasty little bugger and washed out her entire peritoneal cavity with liters and liters of irrigant fluid. [On a faintly related tangent, I still can't believe anyone is routinely doing open appendectomies anymore. Only laparoscopy allows you the capability to drain and lavage the peritoneal cavity for complicated appendicitis]. The next day, she looked remarkably better (normal WBC count, afebrile, etc) but I usually keep kids in the hospital for a few days for IV antibiotics, especially for perforated appendicitis. As I reviewed her chart, I noticed that her Zosyn had fallen off the med list. I asked the nurse and she replied that "pharmacy had called earlier notifying that they were terminating the IV antibiotics 24 hours post surgery."

At this point my jugular vein started throbbing in my neck and my face turned a deep shade of Buckeye scarlett. Why was pharmacy unilaterally cancelling my antibiotic orders and making crucial decisions on the care of my patient?

Here's the deal. My hospital has now implemented a policy of limiting unncecessary use of antibiotics by giving the pharmacy the power to cancel antibiotic orders that extend 24 hours past a patient's surgery date. On the surface, it seems like a reasonable policy. Unnecessary courses of antibiotics have certainly contributed to the preponderance of such modern dilemmas as widespread MRSA infections and toxic megacolon from C Diff colitis. And surgeons who lazily/carelessly forget to cancel prophylactic peri-operative antibiotics are certainly much to blame. But there's a difference between antibiotics for prophylaxis versus antibiotics for the treatment of an infectious process. For perforated appendicitis, I'm not giving Zosyn to reduce my rate of superficial surgical site infections, but rather to actually treat an established, complicated infectious disease.

I spoke with the lead ID pharmacist and he was cool and apologetic about the misunderstanding. But the policy remains unchanged. It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)"

Sunday, July 13, 2008

Surgical Giant





















Farewell to Dr. Michael DeBakey, truly the pre-eminent surgeon of the 20th century. Through sheer effort and creative innovation, he almost single-handedly chiseled out the entire field of cardiovascular surgery on his own. Nowadays, triple and quadruple coronary artery bypass operations have become almost routine. Thoracic aneurysms and dissections are manageable entities. And the techniques were all initially described and honed by Dr. DeBakey. There are stories of him going straight from the OR to his engineer's office to discuss a tool he needed or a device that he had in mind to facillitate a procedure. Bypass roller pumps and Dacron vessel grafts and Ventricular Assist Devices (VAD) and a host of various eponymous surgical instruments were fruits of his labors and dedication. He was a giant of the golden era of medical innovation in general, and surgery in particular. His name goes etched into the pantheon right next to Billroth and Kocher and Halstead.


Some Debakey quotes:
"Man was born to work hard"
"Once you excise the skin, you find they are all very similar"
"I like my work very much. I like it so much I don't want to do anything else."

RIP, Dr DeBakey....

Monday, July 7, 2008

Internal hernia

During my early training, my attendings always hammered home the notion of closing mesenteric defects after open bowel resection cases. The mesentery is a fan-like sheet of peritonealized fat that suspends the bowels and carries the feeding blood vessels. When you do a bowel resection and an anastomosis, there's always a gap in the mesentery that results. Generally, we close these to prevent internal hernias.

Toward the latter years of my training, with the rise of laparoscopic colectomies, I noticed that more often than not, the mesenteric defect would be left alone after a right colectomy. Too much of a pain in the ass to close it laparoscopically. Besides, I was told, the defect was so big, that even if the bowel herniated through it, there was little chance of strangulation.

Well, I saw a lady last week with a classic SBO on initial imaging. A year and a half ago, she had undergone a laparoscopic right hemicolectomy for a villous adenoma at a "major midwestern university program". I put an NG in but she didn't get better. By day #3, her films still looked lousy so I booked her for an exploration. The point of obstruction involved a loop of ileum that had slipped through the mesenteric defect down into the pelvis and, for whatever reason, formed a weird adhesion to the bowel on the other side of the mesentery, thus completely occluding the lumen at that point. The case itself took 5 minutes, snip snip. I also closed the defect with a running suture. I think it will be interesting to see if we start to see more internal hernias from mesenteric defects as we move deeper into the laparoscopic era of bowel surgery.....

Friday, July 4, 2008

Bowel Obstruction























What is a bowel obstruction?
Small bowel obstructions are ubiquitious in the world of general surgery. Most surgeons have one or two lingering on their in-house list at any one time. In the above post, I discussed an unusual cause of SBO, but over 90% are secondary to adhesions. What are adhesions? Scar tissue, baby. Anytime a surgeon has had his/her grubby hands inside your belly, it incites an inflammatory reaction that leads to the formation of fibrous bands and webs. The adhesions can form anywhere; bowel to bowel, bowel to liver, bowel to abdominal wall, just about anything. Generally, the scarring isn't a problem but you have to realize the intestines are constantly in motion, peristalsing and wiggling around inside your belly. Every once in a while, a segment of bowel will flop around a band of scar tissue and it will twist in such a way that the lumen gets either partially or completely occluded.

What does an SBO feel like?
Crampy abdominal pain. Your belly swells. You can't move your stool. You get more and more nauseated until you start vomiting bile in torrents of green. It's miserable, in a word.

What can I do to avoid one?
Nothing. It's not your fault, there's no dietary changes you can implement, no exercise regimen, nothing. A history of abdominal surgery gives you about a 10-20% risk of developing a significant bowel obstruction. Sometimes I use an adhesion barrier product called "Seprafilm" at the end of an open case in the hope that future adhesions will be reduced. There isn't a lot of science to suggest Seprafilm and its competitors actually work, but theoretically it's worth a try. For what it's worth.

What's the treatment?
Most cases can be managed non-operatively. In fact, 70-75% of cases of SBO can be managed without the knife. The key tenets of management are bowel rest, nasogastric decompression, and aggressive rehydration. As a result of vomiting and third spacing of fluid in the bowel wall, patients can get quite dehydrated. You're going to need a couple of liters of saline pumped into you upon arrival in the hospital. And then you're going to have to endure the placement of the dreaded NG tube. On the list of top ten most painful things to undergo, getting an NG tube ranks just below "sawing off your own arm with a penknife to escape from underneath the giant boulder that has you trapped in the desert." Actually it's not that bad. Most of the time it goes in nice and smooth. Just lean forward, sip some water, and try not to fight it too much. The tube is very important and it needs to go down. It's a hose you drop into an overflowing toilet. The sump pump in your flooded basement. Usually a liter or two of foul, feculent greenish-brown slop gets sucked up immediately with a high grade obstruction.

When do you decide to operate Mr. Buckeye Surgeon?
Rarely is it necessary to zip someone off to OR the minute you see them in the emergency room. Bowel obstructions from incarcerated hernias and colonic obstructions obviously need immediate attention. But most SBO's can intially be managed non-operatively. The old adage "never let the sun set on a bowel obstruction" is a little dated. Sort of like catgut sutures and surgical residents working more than 80 hours in a week.

I monitor three things:
1. Pain: Increasing pain suggests bowel ischemia. This is the number one factor I pay attention to. Pain that develops despite NG decompression mandates a trip to the OR. Patients who present with pain will sometimes feel better after a couple hours of NG suctioning. The key thing is to examine the patient serially.

2. White blood cell counts: WBC counts ought to decrease over the first 24-48 hours. Persistent or rising counts are worrisome.

3. Xrays: Least reliable. If the NG is doing its job, the films may very well look better the following day. That doesn't mean the obstruction has resolved, though; it simply means the proximal bowel has been adequately decompressed. Persistent stacked loops of bowel, however, imply a possible closed loop obstruction (proximal and distal ends of a segment of bowel blocked), which will not get better without an operation.I also like CT scans for SBO's. It's a great tool for predicting the likelihood of spontaneous resolution of a patient's bowel obstruction. I look for transition points and possible occult hernias not appreciated on physical exam.

Ultimately, there is no magic formula. It's a judgment call. If the patient isn't progressing, then an operation is justified. The operation itself can often be one of the quickest abdominal procedures in all of general surgery. Sometimes it's a matter of one snip of a single band that has kinked the bowel. Other times, it can be one of the more stressful, time-consuming, and hazardous procedures one will encounter. Patients with multiple previous operations or those who have had radiation treatments for a previous cancer will develop what is known as a "frozen abdomen". Everything is matted together in a single mass. The fused loops of bowel almost look like the surface of a brain. Hours are spent just getting into the abdomen. It's an operation that demands patience and some cool tunes in the background. You can't rush. It shouldn't be a case you do at the end of a long day. Nor should it be the first case on a day when you have five others scheduled. I use the scalpel, for the most part. There's no role for electrocautery; not unless you want to take care of the patient's entercutaneous fistula in a few weeks. It's all sharp dissection, tediously slicing and shaving your way to something at least resembling normal anatomy. It's like carving a serpent out of cement. You can't go on autopilot, like for an inguinal hernia or an elective gallbladder. Every move is an act of improvisation....It's actually sort of fun.